On alert for Ebola

Hawaii’s health-care officials express the fervent hope that current preparations to deal with a future Ebola patient will yield important public-health dividends. However low a risk Ebola poses to Hawaii, they agree that gearing up for one should strengthen capabilities for response to other infectious diseases that are out there  and far more likely to pose a threat here in the Pacific. 

But getting to that point will involve a lot of training, as well as navigating through the shoals of public fears. A lot of that has been on the national news, the latest flare-up occurring between state officials who sought to quarantine Kaci Hickox, a nurse who returned from Africa after working in Ebola clinics but showed no signs of illness. 

Ebola, after all, is the disease that claimed the life of Thomas Eric Duncan last month in Dallas.

 A lot of those worries are to be expected, said Toby Clairmont, but not always rational. 

There was the email from someone on Kauai who suggested that tourists should be barred from the island.

"I’m going, ‘OK, I understand what you’re trying to say — protect Kauai — but I also don’t understand why you’d want to shut off the economic engine for your whole community when the risk isn’t there,’" said Clairmont, director of emergency services for the Healthcare Association of Hawaii. 

It gets worse. The patient count at The Queen’s Medical Center fell off markedly when one person recently there was being evaluated for Ebola, even though tests came up negative. That led local hospitals now being trained as the places best equipped to treat the deadly disease to feel nervous. Health officials declined to identify those hospitals: Why hang the "scarlet letter" on them, Clairmont asked, particularly if they may never be assigned an Ebola case?

"On the mainland there was a teacher from Maine," he added. "She traveled to Dallas, Texas, during the Duncan incident. Never got near the hospital, doesn’t know Duncan. They wouldn’t allow her to come back to work for 21 days. And you’re going, what’s the thought process behind that?"

No thought, just nerves. Dr. Sarah Park, the state epidemiologist, perceives the public anxiety. However, she said, the state Department of Health employs many of the same processes in surveillance and risk assessment for diseases such as measles, several cases of which have been identified recently on Kauai and Maui — tracing contacts, seeing that further exposure is limited.

"There’s a lot of nervousness about how are we going to deal with, control a suspect patient," Park said during a media briefing on Tuesday. "I would emphasize that it’s business as usual, frankly, in many ways for public health.

"If we know of some case, a person out there who we truly suspect has an Ebola infection, we will be reaching out to those we identify who have potential contacts," she added. "We’re not going to be going out there publicly, necessarily.

"While we might inform the public in general to be aware of some of the signs and symptoms, we’re not necessarily going to say, ‘Well, this case was here at this time, this person was there at this time.’ We don’t normally do that." 

What should help with early surveillance is a traveler list that the Centers for Disease Control (CDC) has promised to all states, Park added. Anyone identified by customs agents as having traveled to or from the Ebola-affected countries will be on that list, she said.

A working group convened by the health department has developed a surveillance and patient-management process.

However the potential patient is identified and given their initial interview, Park said the immediate response by the department team that’s called in is to confirm and expand the patient history, gaining a clearer understanding of where they were in an Ebola country, what they did and what kind of protections they had.

For example, she said malaria and typhoid are common diseases in West Africa, so the surveillance team wants to make sure they aren’t at risk of those instead.

"What we hope is that by the intensive investigation that we do, the information we cover, it helps our clinicians better able to treat these patients to not just potentially look at an Ebola patient, but someone who might have other issues," Park said.

In a phone interview with the Star-Advertiser later last week, Park said she knows her counterpart in New Jersey, adding that the decision to quarantine Hickox did not come from the epidemiologist there. Evaluations here would be unlikely to follow such a hard-and fast rule, she added, because the risk such a traveler poses to others is based on individualized circumstances. 

That said, Park acknowledged that some special conditions may apply to health care workers who could have been exposed to the virus. They wouldn’t necessarily be barred from work but would be asked to take some other assignment than patient care, she said.

"They could develop symptoms later, and we wouldn’t know exactly when," she said.

Park also said the state would be willing to issue an official quarantine order if it’s clear the initially voluntary system is insufficient, and has done so previously in cases of tuberculosis. Among the criteria for doing so, she said, is the lack of compliance with voluntary restrictions of movement that the state requests.

Nurses around the state are watching the problem with great interest and some concern. Preparations are underway on multiple fronts. At the University of Hawaii School of Nursing and Dental Hygiene, Lorrie Wong, director of the Translational Health Science Simulation Center, said that facility is being employed in the schooling of nursing students as well as to assist with professional training efforts.

"Our nurses are going to be out there, front line, and we feel an obligation to them," she said. "We want all our nurses to feel confident." 

The main support for the hospitals’ training comes from Clairmont’s nursing crew, a crisis response unit that receives federal money. Over the years these funds have been invested in purchasing a stockpile of personal protection equipment (PPE) suits, the hazmat-style coveralls that have been seen in Ebola news reports. 

The emergency services office also will dispatch a team to help if health-care workers in the community need help with an Ebola case, he said. 

Experts generally believe that Hawaii is at relatively low risk of confronting such a case, although that assessment could change as the outbreak spreads. And while no orders have come yet to the Hawaii National Guard, Maj. Gen. Darryll Wong, the state adjutant general who oversees the force, said that guard units elsewhere already are being called to assist with the development of new clinic facilities in the afflicted countries.

Throughout the health-care profession there is some sympathy for Hickox, who has resisted her quarantining in Maine, and widespread agreement that midterm elections have added a political component to the mix. Making the homecoming for those who volunteer in Africa too onerous likely will cause a chilling effect on that outreach effort, several people agree.

"I think that there needs to be a response to this that is based on science, and it should be universal," said Joan Craft, president of the Hawaii Nurses Association, the professional labor union. "They need to know what they’re doing, and they need to know that what they’re doing is going to work."

On the other hand, Mary Boland, dean of the nursing school, wondered whether Hickox had gone too far in taking her stand. The scientific argument should give way a bit to assuage public fears. "This in an infection that we don’t know everything about," she acknowledged. "And one thing you learn in our business is science is continually changing. You want to err on the side of caution."

Once all the uproar subsides, the result may be better preparedness in Hawaii for the next health crisis, she added.

"There’s going to be a lot of ripples from this that will help in any disaster," Boland said. "It’s too easy for us to get complacent here  these have value as exercises for us and hopefully will strengthen our foundations."